Effectiveness of therapeutic massage for improving motor symptoms in Parkinson's disease: A systematic review and meta-analysis.

Background: Parkinson's disease (PD) causes movement disorders [called motor symptoms (MS)], and motor dysfunction poses a great barrier to the quality of life. Although pharmacological therapy like levodopa can relieve the symptoms, it can also cause complications, such as psychosis, nausea, and dyskinesia. A therapy with more minor side effects is needed for PD. Therapeutic massages are the most commonly used forms of complementary and alternative medicine (CAM), but no systematic review and meta-analysis have focused on the efficacy of massage on PD. Objective: To evaluate the quality of evidence and efficacy of therapeutic massage for improving MS in PD. Methods: We independently searched four electronic databases, including Chinese National Knowledge Infrastructure (CNKI), MEDLINE/PubMed, Embase, and Cochrane Library, for randomized controlled trials (RCTs) about therapeutic massage and other available manual therapies improving MS in PD from January 1, 2012, to December 31, 2021 (recent 10 years). The main outcome measures were total effectiveness and the Unified Parkinson's Disease Rating Scale (UPDRS), including UPDRS total, II, and III. For the statistical analysis, the risk ratio, standard mean difference, and 95% confidence interval (CI) were used to calculate effect sizes between groups. To determine heterogeneity, statistical index I 2 was used. Results: A total of 363 PD participants in seven RCTs and one randomized pilot-control study were included in this meta-analysis. The total effectiveness showed that therapeutic massage was more effective than the intervention of the control group for improving MS [ratio risk (RR): 1.33, 95% CI (1.14-1.55), p = 0.0002]. The UPDRS-III scores showed that massage improves motor function more than the control group [SMD = -0.46, 95% CI (-0.67, -0.24), p < 0.00001]. But we found that massage performed no better than the control group in improving daily life activities [SMD = -0.15, 95% CI (-0.40, 0.10), p = 0.23]. Conclusion: Therapeutic massage was effective in improving MS in PD. It is suggested to be an appropriate form of CAM in treating PD. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=323182, identifier: CRD42022323182.

[Physical therapy for vertebrogenic pain syndrome in patients with non-aggressive vertebral hemangioma]. / Rezul'taty primeneniya fizicheskikh metodov lecheniya patsientov s vertebrogennymi bolevymi sindromami pri nalichii neagressivnoi gemangiomy pozvonka.

The vertebral hemangioma (VH) and vertebrogenic pain syndromes of other etiologies are currently not a problem in terms of the choice of treatment method. However, the combination of these conditions makes the situation much more challenging. The question of the safety of physical treatment methods in these patients remains open, since there is no scientific evidence in this area. OBJECTIVE: To study the long-term results of electrotherapy, magnet therapy, lazer therapy, therapeutic exercises (TE), and therapeutic massage (in different combinations) in patients with degenerative-dystrophic processes of the spine and nonaggressive VH. MATERIAL AND METHODS: The study included 104 patients (75 females, 29 males) with degenerative-dystrophic processes of the spine and non-aggressive VH. The time between the treatment course and follow-up examination was 12 months. RESULTS: VHs remained unchanged in 86.5% of patients. An increase in size was noted in 13.5%. In no case did the VH become aggressive. After the TE course, the rate of VH size increase was 10.8%. The combination of TE with massage and electrotherapy (including a combination of all methods) resulted in an increase in VH size in 17.9, 20.0, 23.8% of cases, respectively. When magnet therapy was used, an increase in VH size was recorded significantly less frequently (p=0.021). No differences in the rate of VH size increase depending on sex, age (40-70 years), localization, and size were observed. In case of multiple VHs, the rate of growth was 23.1. CONCLUSION: A limitation of the study was the relatively small number of patients, which could, in some cases, affect the correctness of statistical data. Nevertheless, there is a general trend of the effect of physical treatments on the course of non-aggressive VH in patients with vertebrogenic pain syndromes. Such patients may be recommended low-frequency low-intensity electro- and magnet therapy, therapeutic back massage, and TE.

Positional release therapy and therapeutic massage reduce muscle trigger and tender points.

OBJECTIVE: To determine if positional release therapy (PRT) or therapeutic massage (TM) was more effective in the treatment of trigger and tender points in the upper trapezius muscle. BACKGROUND: Trigger points in the upper trapezius muscle are common and can be painful. Trigger points are commonly treated using TM however, PRT is a novel treatment that deserves further investigation. METHODS: Sixty healthy male (24) and female (36) participants, (age = 27.1 ± 8.8 years, wt = 75.2 ± 17.9 kg, ht = 172.8 ± 9.7 cm) presenting with upper trapezius pain and a trigger point were recruited and randomized into either the TM or PRT group. Upper trapezius trigger points were found via palpation. Pain level was evaluated using a visual analog scale (VAS) and pain pressure threshold (PPT) was assessed using a pressure algometer. Muscle thickness was measured by B-mode ultrasound, while muscle stiffness was measured by shear-wave elastography (SWE). Participants were measured at baseline, posttreatment and again 48 h later. RESULTS: Both treatments were effective in treatment of pain and muscle stiffness. Although no statistical group differences existed, treatment using PRT showed decreased pain averages and decreased pressure sensitivity at both post treatment, and 48 h later. Neither treatment was able to maintain the reduced muscle stiffness at the 48-h measure in males. CONCLUSION: Both treatments showed a significant ability to reduce pain and acutely decrease muscle stiffness. Although not statistically different, clinically PRT is more effective at decreasing pain, and decreasing pressure sensitivity. Neither treatment method produced a long lasting effect on muscle stiffness in males.

Using a Robot to Treat Non-specific Low Back Pain: Results From a Two-Arm, Single-Blinded, Randomized Controlled Trial.

Non-specific low back pain (NSLBP) affects many people and represents a high cost for health care. Manual pressure release of myofascial trigger points is used to treat NSLBP and is very effective but difficult to standardize since it is provided by different therapists, which also suffer musculoskeletal complications from this highly repetitive activity. A robot designed for this purpose may help in reducing these problems. Here, we present data from a two-arm, single-blinded, randomized controlled clinical trial evaluating the efficiency of a therapeutic massage robot (ADAMO) in reducing NSLBP (clinicaltrials.gov, registration number: NCT04882748). Forty-four patients were randomly distributed into the two arms of the study (robot vs. control). A physician filled the Oswestry disability index (ODI) before starting the treatment and at the end of it, in a blind fashion. In addition, patients filled a visual analogue scale (VAS) after each of the 10 treatment sessions. The ODI and the VAS were analyzed as the primary and secondary outcome measures. Both treatments (robot and control) resulted in a significantly lower ODI (p < 0.05). On the other hand, robot-treated patients significantly reduced their VAS levels (p = 0.0001) whereas control treatment did not reach statistical significance. Patients of both sexes obtained similar benefits from either treatment. Overweight patients (body mass index ≥ 25kg/m2) in the robot arm benefited more from the treatment (p = 0.008) than patients with normal weight. In conclusion, the ADAMO robot is, at least, as efficient as regular treatment in reducing low back pain, and may be more beneficial for specific patients, such as those with excessive weight.

The Effect of Plantar Massage on Static Postural Control in Patients With Chronic Ankle Instability: A Critically Appraised Topic.

Clinical Scenario: Patients with chronic ankle instability (CAI) demonstrate deficits in both sensory and motor function, which can be objectively evaluated through static postural control testing. One intervention that has been suggested to improve somatosensation and, in turn, static postural control is plantar massage. Clinical Question: Does plantar massage improve static postural control during single-limb stance in patients with CAI relative to baseline? Summary of Key Findings: A search was performed for articles exploring the effect of plantar massage on static postural control in individuals with CAI. Three articles were included in this critically appraised topic including 1 randomized controlled trial and 2 crossover studies. All studies supported the use of plantar massage to improve static postural control in patients with CAI. Clinical Bottom Line: There is currently good-quality and consistent evidence that supports the use of plantar massage as an intervention that targets the somatosensory system to improve static postural control in patients with CAI. Future research should focus on incorporating plantar massage as a treatment intervention during long-term rehabilitation protocols for individuals with CAI. Strength of Recommendation: In agreement with the Center of Evidence-Based Medicine, the consistent results from 2 crossover studies and 1 randomized controlled trial designate that there is level B evidence due to consistent, moderate- to high-quality evidence.

What Should We Do Different, More, Start and Stop? Systematic Collection and Dissemination of Massage Education Stakeholder Views from the 2017 Alliance for Massage Therapy Educational Congress.

INTRODUCTION: The Future of MT and Bodywork Forum, held July 27 during the 2017 Alliance for Massage Therapy Education (AFMTE) Educational Congress in Tucson, Arizona, systematically gathered the thoughts and opinions of various massage education stakeholders through an exercise following the principles of the World Café model. METHODS: Forum attendees participated in three, concurrent 30-minute Breakout Group Sessions (Rounds) in three different adjacent rooms, focused on Continuing Education, Schools, or Employment. During each session, participants rotated for 3, 2.5, 2, and 1.5 minutes between four tables, asking what should be stopped, started, done differently, or changed in massage education related to the focus topic. Participants recorded their responses in marker on large Post-it® notes (3M, Maplewood, MN). These were reviewed by each of that round's participants who awarded "importance points" to each response, with 6 blue and 3 orange dots each worth 1 and 3 points, respectively. The Post-it® notes with comments and point allocations were transcribed into a data spreadsheet and analyzed for descriptive statistics and top scoring comments from each room. RESULTS: 85-91 attendees participated in the three breakout sessions resulting in 674 comments with 3,744 assigned value points. The top five scoring comments from each room per session (N = 45) determined stakeholder's most critical views. Stop comments made up the smallest total comments proportion (19%), yet largest top scoring comment proportion (36%)-potentially highlighting unified frustration for various massage education practices. Comparatively, Start comments made up 26% of total comments, but the smallest highest scoring proportion (18%)-perhaps suggesting stakeholders feel it more important to improve what is already being done rather than beginning new endeavors in these areas. CONCLUSION: Stakeholder opinions on the future of massage therapy education can be systematically gathered in large conference settings and organized, analyzed, and disseminated to inform field decision-making.

Model structure for protocol adherence utilizing a manualized therapeutic massage intervention.

Background The Protocol Training and Assessment Model (Model) was developed through collaboration between Emory University School of Medicine and Atlanta School of Massage to minimize intra- and inter-therapist variability for two research massage therapist (rMT) applied intervention arms in the Massage for Cancer-Related Fatigue (MCRF) early-phase study. The Model was followed to maintain and assess protocol integrity for the study's manualized Swedish massage therapy (SMT) and light touch (LT) interventions. Methods The Model includes initial rMT training, quarterly retraining sessions, accessible resources (scripts, treatment guides, weekly research personnel meetings), and ongoing monitoring. Model efficacy was assessed by monitoring data collected at retraining sessions, through audio recording review, and through subject and rMT reporting. Results Model application resulted in a high level of intervention consistency throughout the study. Protocol-related session comment rate by subjects was 2.7%. Few study participants reported intra-rMT or inter-rMT treatment delivery differences. Observation during retraining sessions indicated massage therapists continued to adhere to protocols. Importantly rMTs increased their participation beyond core duties, suggesting additional ways to standardize subject treatment experience. Conclusions Through systematic application of the Protocol Training and Assessment Model, continuous and collaborative quality improvement discussions between scientists and research massage therapists resulted in reliable, standardized SMT and LT interventions for the MCRF early-phase study. Future research can apply the Model to support and assess consistent rMT-delivered intervention applications.

Management of behavioural and psychological symptoms of dementia by an aroma-massage with acupressure treatment protocol: A randomised clinical trial.

AIMS AND OBJECTIVES: This study evaluates the clinical effectiveness of a multicomponent aroma-massage with an acupressure treatment protocol and compared it to cognitive training for the management of behavioural and psychological symptoms of dementia. BACKGROUND: Pharmacological interventions have been unsatisfactory in managing behavioural and psychological symptoms of dementia; thus, complementary and alternative medicine has been extensively researched to identify an adjunct safe and cost-effective intervention. DESIGN: This randomised clinical trial utilised a three-arm parallel group design. Cognitive training was used as a conventional intervention to manage behavioural and psychological symptoms of dementia, whereas exercise was considered "treatment as usual" in this study; both were used as comparisons with the experimental protocol. There were three treatment groups: Group 1: aroma-massage with acupressure + exercise, Group 2: cognitive training + exercise and Group 3: aroma-massage with acupressure + cognitive training. METHOD: Sixty older adults were recruited and randomly assigned to the three groups (20 each). Using the 29-item Chinese Version of the Cohen-Mansfield Agitation Inventory, Neuropsychiatric Inventory, Mini-mental State Examination and Barthel Index-20, the outcome measures were assessed at preintervention, postintervention and the 3-month follow-up to assess behaviour, Activities of Daily Living, cognition, and behavioural and psychological symptoms of dementia severity and distress. Multiple comparisons performed through repeated measures were analysed to detect between-group differences and within-subject differences, as well as the interaction effects between groups and times. RESULTS: The Group 1 and 3 participants showed a significant reduction in the severity and distress caused by behavioural and psychological symptoms of dementia, whereas Group 2 did not demonstrate similar effects. CONCLUSIONS: This clinical study suggests that aroma-massage with acupressure is as effective as cognitive training and can enhance cognitive training in reducing the severity and distress of behavioural and psychological symptoms of dementia. RELEVANCE TO CLINICAL PRACTICE: Aroma-massage with acupressure may serve as an adjunct therapy to reduce behavioural and psychological symptoms of dementia. This therapy is safe, cost-effective and can be implemented by caregivers and family members who are not professionally trained.

Impact of Massage Therapy on Fatigue, Pain, and Spasticity in People with Multiple Sclerosis: a Pilot Study.

BACKGROUND: Multiple sclerosis (MS) is a chronic, immune-mediated, inflammatory disease that leads to fatigue, pain, and spasticity, as well as other sensorimotor and cognitive changes. Often traditional medical approaches are ineffective in alleviating these disruptive symptoms. Although about one-third of surveyed individuals report they use massage therapy (MT) as an adjunct to medical treatment, there is little empirical evidence that MT is effective for symptom management in people with MS. PURPOSE: To measure the effects of MT on fatigue, pain, spasticity, perception of health, and quality of life in people with MS. SETTING: Not-for-profit long-term care facility. PARTICIPANTS: Twenty-four of 28 enrolled individuals with MS (average age = 47.38, SD = 13.05; 22 female) completed all MT sessions and outcome assessments. RESEARCH DESIGN: Nonrandomized, pre-post pilot study. INTERVENTION: Standardized MT routine one time a week for six weeks. MAIN OUTCOME MEASURES: Modified Fatigue Index Scale (MFIS), MOS Pain Effects Scale (MOS Pain), and Modified Ashworth Scale (MAS). Secondary outcome measures: Mental Health Inventory (MHI) and Health Status Questionnaire (HSQ). RESULTS: There was a significant improvement in MFIS (p < .01), MOS Pain (p < .01), MHI (p < .01), and HSQ (p < .01), all with a large effect size (ES) (Cohen's d = -0.76, 1.25, 0.93, -1.01, respectively). There was a significant correlation between change scores on the MFIS and the MOS Pain (r = 0.532, p < .01), MHI (r = -0.647, p < .01), and subscales of the HSQ (ranging from r = -0.519, to -0.619, p < .01). CONCLUSIONS: MT as delivered in this study is a safe and beneficial intervention for management of fatigue and pain in people with MS. Decreasing fatigue and pain appears to correlate with improvement in quality of life, which is meaningful for people with MS who have a chronic disease resulting in long-term health care needs.

Perception about the importance and use of therapeutic massage as a treatment modality among physical therapists working in Saudi Arabia.

[Purpose] To report perceptions about the importance and use of therapeutic massage as a treatment modality among physical therapists working in Saudi Arabia. [Subjects and Methods] A 21-item structured questionnaire was used to assess various domains including the demographic and professional characteristics of physical therapists and their perceptions about the importance and use of therapeutic massage in their daily practice. The questionnaire was uploaded online and the web link was sent to 140 members of the Saudi Physical Therapy Association (SPTA). [Results] The overall response rate was 86%. Among the respondents, 31% reported occasional use of therapeutic massage in their clinical practice, and 55% reported to have received formal training for therapeutic massage. Use of therapeutic massage was more common among female physical therapists. [Conclusion] Many physical therapists working in Saudi Arabia consider therapeutic massage to be an important treatment modality, but its use is relatively limited, either due to the time and effort required to dispense it, or the lack of scientific evidence for its efficacy.

Efecto del masaje terapéutico como cuidado de enfermería en la capacidad funcional del adulto mayor / The effect of therapeutic massage as part of nursing care for the functional capacity of the elderly / Efeito da massagem terapêutica como cuidado da enfermagem na capacidade funcional do idoso

Objetivo: Evaluar el efecto del masaje terapéutico clásico como cuidado de enfermería en la capacidad funcional del adulto mayor en una casa hogar. Métodos: Estudio cuantitativo, longitudinal, cuasiexperimental. Se evaluó la capacidad funcional del adulto mayor antes y después del masaje terapéutico clásico con el índice de Barthel, alfa de Cronbach de 0.95. Muestreo no probabilístico por conveniencia. En total se estudiaron 15 adultos mayores divididos aleatoriamente en grupo de estudio y control, con base en Epidat 3.1. El análisis se realizó con estadística descriptiva y no paramétrica a través de T de Wilcoxon y U de Mann Whitney para lo cual se utilizó el programa SPSS v.19. Resultados: El promedio de edad fue de 84.14 ± 9.68 vs. 80.25 ± 10.49 para el grupo control y de estudio respectivamente; el 73% del género masculino. Previo y posterior al masaje terapéutico en la prueba de Wilcoxon, el resultado fue: grupo control (Z = 0, p = 1) vs. grupo experimental (Z = 2.47, p = 0.01). En la U de Mann Whitney (U = 0.5, p = 0.001). En la posprueba del grupo de estudio se observó un aumento significativo de la capacidad funcional. No existen estudios similares, sin embargo, algunas investigaciones han demostrado que el masaje terapéutico es efectivo para mejorar el dolor, la amplitud de movimiento y la fuerza de agarre en adultos mayores. Conclusiones: El masaje terapéutico clásico es efectivo para incrementar la capacidad funcional del adulto mayor institucionalizado.

Objective: To assess the effect of traditional therapeutic massage on the functional capacity of elderly adults in a residential care facility. Methods: Quasi-experimental, longitudinal and quantitative study. The elderly adults' functional capacity was assessed before and after the classic therapeutic massage using Barthel's index. Cronbach alpha turned out to be 0.95. The sampling was by convenience and not probabilistic. In total, 15 studied elderly adults were randomly assigned to a control group and a study group using Epidat 3.1. Descriptive and not parametric analysis was performed using Wilcoxon T and Mann Whitney U tests with the SPSS v.19 program. Results: The average age was 84.14 ± 9.68 and 80.25 ± 10.49 in the control and study groups respectively. Seventy-three percent were masculine. The Wilcoxon test results were Z = 0, P = 1 in the control group, and Z = 2.47, P = .01 in the experimental group. The Mann Whitney test result was U = 0.5, P = .001. The study group post-test showed a significant increase in the functional capacity. There are not many similar works in the literature; however some research studies have demonstrated that therapeutic massage is effective in improving movement and gripping strength, and also in reducing pain among elderly adults. Conclusions: Traditional therapeutic massage is effective in increasing the functional capacity of institutionalized elderly adults.

Objetivo: Avaliar o efeito da massagem terapêutica clássica como um cuidado de enfermagem na capacidade funcional do idoso no Lar. Métodos: Estudo qualitativo, longitudinal, quase experimental. Avaliou-se a capacidade funcional do idoso antes e depois da massagem terapêutica clássica com o índice de Barthel, alfa de Cronbach de 0.95. Amostragem não probabilística por conveniência. No total estudaram-se 15 idosos divididos aleatoriamente em grupo de estudo e de controle, utilizando Epidat 3.1. A análise realizou-se com estatística descritiva e não paramédica a través de T de Wilcoxon e U de Mann Whitney para o qual se utilizou o programa SPSS v. 19. Resultados: A média de idade foi de 84.14 ± 9.68 vs 80.25 ± 10.49 grupo controle e de estudo respectivamente, 73% gênero masculino. Prévio e posterior à massagem terapêutica na prova de Wilcoxon, o resultado foi: o grupo controle (Z = 0, p = 1) vs grupo experimental (Z = 2.47, p = 0.01). No U de Mann Whitney (U = 0.5, p = 0.001). No pós-teste do grupo de estudo observou-se um aumento significativo da capacidade funcional. Não existem estudos similares, porém, algumas pesquisas têm demonstrado que a massagem terapêutica é efetiva para a melhoria da dor, da amplitude de movimento e da força de preensão em idosos. Conclusões: A massagem terapêutica clássica é efetiva para incrementar a capacidade funcional do idoso numa instituição.

Gentle Massage Improves Disease- and Treatment-Related Symptoms in Patients with Acute Myelogenous Leukemia.

OBJECTIVE: Cancer treatment is reported to be stressful, and patients diagnosed with hematologic cancers often exhibit higher levels of anxiety and emotional distress than individuals with other malignancies. Management of these symptoms in patients with hematologic cancer presents significant challenges, as many of them are in and out of the hospital while undergoing high dose chemotherapy. Oncology patients use complementary modalities such as therapeutic massage in an attempt to alleviate disease and treatment-related symptoms, including anxiety and emotional distress. In the current study, the feasibility of a novel massage intervention delivered over the continuum of care, as well as assessment of the immediate and cumulative effects of massage, was examined in patients with acute myelogenous leukemia. METHODS: A mixed-methods, unmasked, prospective, randomized study was conducted with two groups: a usual care alone control group and a massage therapy intervention plus usual care group. RESULTS: Significant improvements in levels of stress and health-related quality of life were observed in the massage therapy group versus the usual care alone group, after adjusting for anxiety level, including both immediate and cumulative effects of massage. CONCLUSIONS: While the findings of the current study regarding acceptability, feasibility, and potential efficacy of therapeutic massage as a complementary health-enhancing intervention in patients diagnosed with acute myelogenous leukemia are very promising, the relatively small size of the study sample limits generalizability.

Qualitative study of women's experience after therapeutic massage.

BACKGROUND: Hypertension has become a major problem throughout the world, especially in developing countries like Iran. As it is a major risk factor for coronary heart disease, even small reductions in the prevalence can have potentially large public health benefits. Among the complementary methods, massage provides an effective means to lower the blood pressure. If nurses perceive the experiences of hypertensive patients receiving massage, they can use massage more effectively in their care plan. MATERIALS AND METHODS: This is a descriptive phenomenological study. Deep interviews were conducted with nine prehypertensive women who received Swedish massage three times a week in a total of 10 sessions, with each session lasting 10-15 min. Then, the researcher conducted an interview using a 'grand tour question (open ended question) and the participants were then encouraged to speak freely explaining their thoughts and feelings about the experience of massage therapy. Data analysis was done by Colaizzi's method. Validity and reliability were obtained through measures such as real value, applicability, continuity, and authenticity. RESULTS: Women evaluated the massage therapy positively. The findings yielded six themes, including relaxation, sleeping better, reduction of anxiety and tension, reduction of fatigue, invigorating experience, improve connecting. CONCLUSIONS: This study demonstrates that a body-centered intervention like massage can be valuable in a multidisciplinary approach to women with prehypertension. This method is easy to learn and relatively short (10-15 min) to administer as a suitable complement in nursing care for this group of patients.

Randomised controlled trial of the effectiveness of using back massage to improve sleep quality among Taiwanese insomnia postpartumwomen.

OBJECTIVE: to examine the effectiveness of using back massage to improve sleep quality in postpartum women. DESIGN AND SETTING: randomised controlled trial, conducted at a postpartum centre in Northern Taiwan. PARTICIPANTS: sixty postpartum women reporting poor quality of sleep were recruited from February 2012 to May 2012. INTERVENTIONS: participants were assigned randomly to either an intervention or a control group. Participants in both groups received the same care except for back massage therapy. The intervention group received a single 20-minutes back massage session at the same time each evening for 5 consecutive days. Sessions were administered by a certified massage therapist. MEASURES AND FINDING: the outcome measure was the Pittsburgh Sleep Quality Index (PSQI), which was administered pre- and post-test. Using a generalised estimation equation to control several confounding variables, the changes in mean PSQI were significantly lower in the intervention group (B=-3.97, standard error=0.43, p<0.001) than in the control group. CONCLUSIONS: an intervention involving back massage in the postnatal period significantly improved the quality of sleep. IMPLICATIONS FOR PRACTICE: midwives should evaluate maternal sleep quality and design early intervention programs to improve the quality of sleep, to increase maternal health. Midwives interested in complementary therapies should be encouraged to obtain training in back massage and to apply it in postpartumcare.